Presentation Transcript

1. Health Plan-ACO-Employer Perspectives on the “Cancer Spend” Ira M. Klein, M.D., MBA, FACP
2. Panelists Moderator: Ira M. Klein, M.D., MBA, FACP National Medical Director, Clinical Thought Leadership, Office of the Chief Medical Officer, Aetna Panelists: Roy Beveridge, M.D., Chief Medical Officer, Humana Ron Finch, Ed.D., Vice President, National Business Group on Health Frank Flosman, Vice President & Regional Lead, Aetna Consulting Michael Kolodziej, M.D., National Medical Director Oncology Solutions, Aetna
3. Health Plan-ACO-Employer Perspectives on the “Cancer Spend” Roy Beveridge, MD Chief Medical Officer Humana Inc.
4. Disclosure Information Roy Beveridge, M.D. Employment or Leadership Position: Humana Inc., Chief Medical Officer Stock Ownership: Humana Inc. Please note, all disclosures are reported as submitted to the Cancer Center Business Summit and are available at cancerbusinesssummit.com.
5. Example: Primary Care Linkage of Quality to Cost HEDIS Performance improves with higher levels of integrated care Cost improves with higher levels of integrated care
6. Radiology Benefit Management Diagnostic and Radiation Therapy Services Consultative Model Evidence-based care determinations by like Clinical Specialty Treatment plan review for appropriate utilization of modality and in radiation therapy the fraction dose and schedule Case Rates Simplifies provider and plan interaction and authorization Demonstrating high quality and evidence based care Physician managed utilization lowers overall treatment costs
7. Oncology Quality Management Medical Oncology Treatment Plan Review which: Supports evidence-based care and administrative efficiencies Aligns quality metrics to financial rewards, supported by enhanced reimbursement for generic drugs Develops collaborative relationships with oncology providers Identifies errors in drug, dose, or indications in 3-5% of treatment plans Example results with participating oncology providers Large Midwestern academic medical center: 92% Pathway Entire network – Eastern State: 72% Pathway
8. Specialty Care - Risk or Not to Risk: The Continuum Population Management for Large and Small Organizations Full Risk: Population Management Risk Level Episodic Risk: Procedural Based Risk Level No Risk: FFS, Quality Bonus 25% of providers who are risk averse 50% of providers who “stop” accepting risk beyond a procedure or episodic event – BUNDLED PAYMENT 25% of providers who move beyond bundled payment risk to full risk arrangements Many groups acceptance of risk may not move beyond the risk of a single member’s case/episode/procedure Some groups will not accept risk or will move to risk only if regulated Bundled payments are a tool to move groups into capitation and full risk relationships: bundles test hospital-physician coordination and risk tolerance Oncology Provider Risk Continuum
9. Health Plan-ACO-Employer Perspectives on the “Cancer Spend” Michael Kolodziej, M.D., National Medical Director Oncology Solutions
10. Disclosure Information Michael Kolodziej, M.D. Employment or Leadership Position: Aetna,Medical Director Please note, all disclosures are reported as submitted to the Cancer Center Business Summit and are available at cancerbusinesssummit.com.
11. Oncologists will need to develop capabilities to transition to a medical home. We can help them. Oncology Medical Home Solution Information Technology Clinical decision support tools to optimize care plan Automated prior-authorization to reduce administrative burden Provider Tools Care Management Support Optimal Staffing Model to provide leverage and coordinate care Oncology-tailored patient applications to support patients Patient Tools Financial Alignment IT platform for care transitions and holistic view of patients Value based contracting and benefit steerage to drive adoption HIT Platform
12. Health Plan-ACO-Employer Perspectives on the “Cancer Spend” Frank G. Flosman, MBA
13. Disclosure Information Frank Flosman Employment or Leadership Position: None Please note, all disclosures are reported as submitted to the Cancer Center Business Summit and are available at cancerbusinesssummit.com.
14. Impacts of Change on the Provider/Payer Relationship Opportunities For Oncologists Historical Model: Volume Based New Model: Value Based Care Delivery Fragmented Episodic Variable Coordination Growth Inpatient Infrastructure Chase Reimbursement Quality Serve as Secondary Metrics Retrospective Revenue Individual Service Fees More is More Payments Considerations Denials Utilization review Relationships Adversarial Mis-Aligned Incentives Care Delivery Integrated/Evidenced Based Population Health Focused Coordination Across Continuum Growth Strategic/Integrated Investments Improve Care Cost and Efficiency Quality Drive Payments/Incentives Pro-Actively Managed Revenue Service Line/PHM Based Performance Metric Driven Payments Considerations Align Incentives Reward Performance Relationships Partnerships Align Incentives Care Delivery Wealth of Best Practice Expand Multi-Disciplinary Approach Growth Drive Strategy Participate in Efficiency Quality Leverage Data ( Registries) Participate in Management Revenue Positioned in Service Live Expand Use of Metrics Payments Considerations Open to New Alignments Publicize Performance Relationships Partnerships Align Incentives
15. The Path To Value and Accountable Care Accountable Care Risk Management Clinical Integration Workflow Management Workflow Management Outcomes Management Outcomes Management Analytics Analytics Meaningful Use HIE HIE HIE EMR EMR EMR Clinical Decision Support Clinical Decision Support Clinical Decision Support Coordinate Patients/ Services Care Management Clinical Data Integration Manage Performance Personal Health Records Registries Integrated Care Management Communication/Workflow Manage Populations Align Services With Stratified Populations Educate/Inform Engagement Patients In Options
16. The Process Of Value-Based Transformation Key Elements of Value Based Transformation Manage Population Health Across Continuum Maximize Membership Fully Integrate Data Transfer Optimize Patient Experience Manage Risk Bridge Gap Between Business Models Reduce Costs Manage Resources Build Operating structures Develop Capabilities Integrate Care Delivery Manage Change Formal partnership Value-Based Care TRANSFORMATIONPROCESS Assess Readiness Identify Risks Build Consensus Long Term Growth Strategies *Redesign Org Structures and Service Lines Around PHM Adopt Performance Management Across the Care Continuum Manage Change Improve Operating Efficiencies Reduce Costs Align Resources /Processes W/ Demand Build/Refine Performance Management Tools and Metrics Develop Financial Models Align Operations with PHM* Redesign Processes Build Operating Models Create Viable Market Strategies Manage Change *Assess Capabilities Determine Market Opportunities Identify Financial Impacts * Population Health Management models and tools (Care Management, HIT, etc.) Key Tasks Required For Transformation
17. Health Plan-ACO-Employer Perspectives on the “Cancer Spend” Ron Finch, Ed.D., Vice President, National Business Group on Health

18. Health Plan-ACO-Employer Perspectives on the “Cancer Spend”2013 Cancer Business Summit

    Ron Finch, EdD Vice President National Business Group on Health October 24, 2013
19. About the National Business Group on Health Represents approximately 377 large, self-funded employers, including two-thirds of the Fortune 100; offices in Washington, DC The nation’s only non-profit organization devoted exclusively to: Finding innovative and forward-thinking solutions to large employers’ health care and related benefits issues Speaking for large employers on national and state health Issues NBGH members provide health care coverage to over 50 million U.S. workers, retirees and their families
20. Why Is Cancer Important to Employers? Acute cancers affect 2.4% of all beneficiaries covered by employers 10.5% of total employer-sponsored health care Estimated $124 billion in direct medical costs1 Cost to American companies is over $264 billion per year in health care costs and lost productivity An estimated $19 billion in lost productivity due to illness $123 billion in lost productivity due to premature death2 Absenteeism and “presenteeism” are 4 times greater than treatment costs 1American Cancer Society. Cancer Facts & Figures 2012. (Revised 2/9/2012) 2Loeppke et al, Health and Productivity as a Business Strategy; Journal of Occupational and Environmental Medicine, July 2007
21. Why Is Cancer Important to Employers? Leading cause of long-term disability – about 17% of claims1 Caregiving issues More than half of women and a third of men experience workday interruptions as a result of caregiving responsibilities 12% of employees who take FML are on STD within 6 months2 18% of employees on FML for their own illness, on STD within 6 months2 Leading cause of unaddressed costs3 Leading disease cause of death for children between infancy and age 154 1UnumProvident Company, 2005 2Reed Group, 2012 3Kessler, Ronald C. PhD, et. al, The Effects of Chronic Medical Conditions on Work Loss and Work Cutback, JOEM, vol. 43, No. 3, March 2001 4 National Cancer Institute, A Snapshot of Pediatric Cancer, 2010
22. What Employers Want Evidence-based Benefits Personalized Care Vertical and Horizontal Benefit Integration Standardization Accountability Contracted with NCCN--has the evidence/NBGH can work to translate the evidence
23. Approach Health Care Benefits Plan General Medical Pharmacy Health and Productivity Short- & Long-Term Disability Family Medical Leave Employee Assistance Programs Health Promotion/Wellness Beneficiary Education Prevention, Screening & Surveillance Survivorship Working group consists of staff from NBGH and NCCN, supported by an Advisory Committee that includes representatives from all stakeholder groups: Managed care plans PBMs Cancer centers (physicians) Employers/benefit managers Patient advocates Pharmaceutical industry American Cancer Society Benefit consultants Disability & EAP vendors Advisory Committee approves all deliverables. All resources developed through this collaboration are available free to all.
24. Employer Toolkit Quick Assessment Tool Employer Benefit Assessment & Design Tool Program Evaluation Tool Evaluation of processes, policies, procedures RFP & Proposal Scoring Tool Vendor Program Contracting Tool What is available and where and why important
25. Tool 1 – Quick Reference Guide: A brief summary of benefit and program recommendations across the benefit continuum. Tool 2 – Employer Benefit Design and Assessment: Provides practice recommendations and suggestions for comprehensive benefits, along with a methodology employers can use to assess their current benefits. Includes recommendations related to medical and pharmacy benefits, short-term disability, family medical leave and employee assistance programs and health improvement programs. The Toolkit
26. The Toolkit Tool 3 – RFP and Proposal Scoring Tools: Resources to support implementation of recommendations from Tool 2. Part I details RFP questions and response requirements. Part II includes evaluation criteria for vendor responses. Part III provides a scoring tool to facilitate rating and ranking of vendor responses. Tool 4 – SPD Guidance: Offers guidance to help employers translate the recommended benefit or practice into summary plan description language for beneficiaries.
27. The Toolkit Tool 5 – Vendor Contracting and Administration: Includes reporting requirements and timing. Tool 6 – Vendor and Program Evaluation: Supports assessment of vendor performance and overall effectiveness of the entire set of employee benefits. Tools and Resources can be found: www.businessgrouphealth.org/cancer